Block 13 Flashcards
What are Parkes’ 4 Phase of Grief?
- numbness
- yearning/pining and anger
- disorganisation and despair
- reorganisation
What are the 6 aspects of acute grief (according to Lindemann)?
- somatic or bodily distress
- preoccupation with the image of the deceased
- guilt relating to the deceased or circumstances of the death
- hostile reactions
- inability to function as one had before the loss
- development of traits of the deceased in own behaviour
What are Worden’s 4 Tasks of Mourning?
- accept the reality of the loss
- work through the pain of grief
- adjust to an environment in which the deceased is missing
- emotionally relocate the deceased and move on with life
What factors affect grief severity?
- closeness of relationship
- meaningfulness of relationship
- nature of relationship prior to death
- expectedness and manner of death
- age and developmental stage of griever
- individual resilience (function of: neuroticism, introversion, childhood trauma, parenting)
- attachment and dependency
- religious / spiritual beliefs
- social support
What are the 4 types of infant attachment described by Ainsworth?
- secure attachment
- anxious ambivalent/resistant attachment
- anxious avoidant attachment
- disorganised attachment
How can religious belief impact on bereavement?
- belief in an afterlife
- continued attachment beyond death (e.g. through prayer)
- a defence against fear of personal death
- funeral rituals aid and progress grief
- funeral rituals recruit social support
What is palliative care?
- active, holistic care of patient with advanced, progressive illness
- management of pain and other symptoms and provision of psychological, social and spiritual support
- goal is to achieve best quality of life for patients and their families
What types of services contribute to generalist palliative care?
- primary care
- nursing home
- secondary care
- social services
What types of services contribute to specialist palliative care?
- clinical nurse specialists (in hospital and community)
- specialist physicians in palliative care
- hospices
- marie curie nurses
Who provides and funds palliative care?
NHS
- specialist nurses
- some consultants
- some in-patient units
- macmillan nurses
Voluntary sector
- hospices
- marie curie nurses
- macmillan nurses
What services do hospices provide?
- in-patient beds
- day hospice
- medical clinics
- complementary therapies
- education
- bereavement services
- out-of-hours advice
- hospice at home
- benefits advice
What types of nurses may be involved in palliative care and what are their roles?
- district nurses (generalist palliative skills, “hands on” nursing skills, work in the community)
- practice nurses (practice based, generalist palliative skills, “hands on” nursing skills)
- marie curie nurses (community based, arranged by district nurses, specialist palliative care skills and “hands on” nursing skills)
- macmillan nurses (community or hospital based, specialist palliative care, advice, support, signposting)
More people die globally of _____ than any other cause.
CVD
> 75% of CVD deaths are in…
low and middle income countries
What two factors affect PARP?
- RR
- prevalence
What is PARP?
- population attributable risk proportion
- the proportion of disease in a population which is attributable to a particular exposure
What is the prevention paradox?
A preventative measure that brings large benefit to the community offers little to each participating individual
What are the pros of aiming risk reducing interventions at high risk individuals?
- intervention is appropriate to the individual
- they are likely a motivated participant
- the clinician will be motivated
- cost-effective resource use
- benefit:risk is high
What are the cons of aiming risk reducing interventions at high risk individuals?
- screening is difficult
- benefits may only be palliative or temporary
- limited potential gains
- labelling/stigma to high risk individuals
What are the pros of aiming risk reducing interventions at low risk individuals?
- large potential gains
What are the cons of aiming risk reducing interventions at low risk individuals?
- population paradox (small individual benefit)
- poor motivation from individuals and potentially from clinicians
- benefit:risk is low
What is decision analysis based on?
A normative theory of decision making: subjective expected utility theory (SEUT)
What are the assumptions of decision analysis?
- decision process is logical and rational
- a rational decision maker will choose the option to maximise utility (the desirability or value attached to a decision outcome)
What is decision analysis?
- a systematic, explicit, quantitative way of making decisions in healthcare that can lead to both enhanced communication about clinical controversies and better decisions
What does decision analysis do?
- assists in understanding of a decision task
- divides decision task into components
- uses decision trees to structure the task:
- uses evidence in the form of probabilities so we can examine the risks associated with each option
- examines the utility or cost associated with each option and gives it an actual value
- suggests the most appropriate decision option for that particular situation using calculations
What are the components of an evidence based decision?
- evidence from research
- patient preferences
- available resources
- clinical expertise
How does decision analysis align with evidence-based decision making?
Aligns well:
- decisions are based on empirical evidence about effectiveness and prognosis from RCTs and cohort studies
- it also draws on values attached to the outcomes which are derived from the patient(s) or health economics
What are the stages in a decision analysis?
- structure the problem as a decision tree - identifying choices, information, and preferences
- assess the probability of every choice in the tree
- assess numerically the utility of every outcome state
- identify the option that maximised expected utility
- conduct a sensitivity analysis to explore the effect of varying judgements
What do the different symbols mean on a decision tree?
- square - a decision, a choice between two actions
- circle - chance, uncertainty, potential outcomes of each decision
- triangle - value of outcome state (higher is better)
Each time the decision tree branches the values must equal…
1
How might you measure patient experience / acceptability of treatment for consideration in a decision analysis? What is another name for these measures?
- EQ5D questionnaire
- visual analogue scale
- QALYs
AKA utility measures
How do you calculate from a decision tree?
- work right to left
What is a sensitivity analysis? Why would you do it?
- necessary if numbers are uncertain
- calculate the effect different values would have on the outcome
- you vary the uncertain variables over a plausible range and calculate the effect of uncertainty on the decision
What are the benefits of decision analysis?
- makes all assumptions in a decision explicit
- allows examination of the decision making process
- integrates research evidence into the decision process
- insight gained during process may be more important than the numbers generated
- can be used for individual decisions, population level decisions and for cost-effectiveness analysis
What are the limitations of decision analysis?
Probability estimates:
- data required to estimate probabilities may not exist
- subjective probability estimates could build bias into the decision
Utility measures:
- individuals may be asked to rate a state of health they have not yet experienced
- different techniques will result in different numbers (not reliable)
- subject to presentation framing effects (e.g. survival, death)
- reductionist approach (takes complex health states and assigns numbers to them - must be oversimplification)
